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Search results for "United States of America"

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Journal Article > Commentary

Enhanced time out: an improved communication process.

Nelson PE. AORN J. 2017;105:564-570.

The Universal Protocol requires hospitals to adopt time outs as a strategy to prevent wrong-site surgeries. This commentary describes how one organization combined elements of time outs and the surgical safety checklist to augment communication and teamwork in surgical settings. Implementation of the enhanced time out involved targeted education and clarity around surgical roles and responsibilities.

Book/Report

Adverse Health Events in Minnesota: 13th Annual Public Report.

St. Paul, MN: Minnesota Department of Health; February 2017.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2016 report summarizes information about 336 adverse events that were reported and found that while deaths due to medical error rose, the number of falls and fall-related deaths reached the lowest point since 2011. There were no reported incidence of patient suicide for the first time since 2011. Reports from previous years are also available.

Book/Report

Advancing Patient Safety in Cataract Surgery: A Betsy Lehman Center Expert Panel Report.

Boston, MA: Betsy Lehman Center for Patient Safety and Medical Error Reduction; 2016.

Cataract surgery, one of the most common procedures in the United States, is vulnerable to wrong-site errors. This consensus report reviews the types of errors associated with cataract surgery and discusses evidence-based practices to reduce risks.

Newspaper/Magazine Article

When a surgeon should just say 'I'm sorry'.

Cohen E. CNN. March 24, 2016.

Poor communication regarding medical errors can contribute to patient and family frustration and fear. Reporting on a case involving disclosure of a wrong-site surgery, this news article describes a resolution program to help patients cope after a preventable error. The program includes apology, disclosure, and explanation of what occurred as well as financial compensation.

Journal Article > Study

The contribution of sociotechnical factors to health information technology–related sentinel events.

Castro GM, Buczkowski L, Hafner JM. Jt Comm J Qual Patient Saf. 2016;42:70-79.

This study reviewed sentinel events reported to The Joint Commission between 2010 and 2013 to examine how health information technology (IT) may contribute to serious adverse outcomes. The most frequently identified health IT–related sentinel events were medication errors, wrong-site surgery, and delays in treatment.

Journal Article > Review

Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events.

Hempel S, Maggard-Gibbons M, Nguyen DK, et al. JAMA Surg. 2015;150:796-805.

This systematic review examined surgical never events following the implementation of the Universal Protocol in 2004. Incidence estimates for retained surgical items and wrong-site surgery varied across studies, with median event rates approximately 1 per 10,000 and 1 per 100,000 procedures, respectively. There were many causes and contributing factors to these errors, but root cause analyses commonly called for better communication.

Journal Article > Review

Concept analysis: wrong-site surgery.

Watson DS. AORN J. 2015;101:650-656.

Despite large-scale efforts to prevent wrong-site surgeries, they continue to occur. This concept analysis found limited evidence regarding the role of nurses in wrong-site surgery and recommends that future research focus on theoretical frameworks around how preoperative nurses can help avert these never events.

Book/Report

Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project.

  • Classic

Chicago, IL: American Hospital Association, Health Research and Educational Trust, and Joint Commission Center for Transforming Healthcare; 2014.

Wrong-site surgery is a never event, but still occurs at alarming rates. This report discusses risks related to wrong-site surgery, along with their root causes, and describes initiatives associated with a Joint Commission Center for Transforming Healthcare project. The authors highlight improvements in scheduling surgeries, preoperative processes, operating room preparations, and organizational culture that substantially reduced wrong-site surgeries in the eight hospitals participating in the program. A prior AHRQ WebM&M commentary by Dr. Charles Vincent discussed a case of a wrong-site procedure.

Journal Article > Study

Wrong-side thoracentesis: lessons learned from root cause analysis.

Miller KE, Mims M, Paull DE, et al. JAMA Surg. 2014;149:774-779.

Wrong-site procedures result in significant patient harm, and prior studies have shown that—contrary to traditional assumptions—many of these errors occur outside the operating room. This analysis of 14 cases of wrong-site thoracenteses, a procedure to remove fluid from around the lung, identified several common themes in these errors. The majority of errors resulted in serious patient injury. Root cause analysis of the errors found that clinicians often failed to perform a time out and did not correctly document laterality in consent forms and clinical records. A case of a wrong-side thoracentesis that resulted in the death of a patient is discussed in a previous AHRQ WebM&M commentary.

Journal Article > Study

"It is the left eye, right?"

Pikkel D, Sharabi-Nov A, Pikkel J. Risk Manag Healthc Policy. 2014;7:77-80.

In this study, cataract surgeons were asked to identify the correct eye for surgery when given the patient's name only, and again while looking at the patient's face. The surgeons answered incorrectly approximately a quarter of the time, arguing for the importance of preoperative time outs to avoid wrong-site surgery.

Journal Article > Study

A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus.

Alam M, Lee A, Ibrahimi OA, et al; Cutaneous Surgery Consensus Group. JAMA Dermatol. 2014;150:550-558.

Excisional skin cancer surgery is a common procedure often performed many days after an initial biopsy by a different physician, making it particularly vulnerable to wrong-site surgery. This study provides a range of consensus recommendations for medical professionals and patients to reduce such risks.

Journal Article > Study

Using "near misses" analysis to prevent wrong-site surgery.

Yoon RS, Alaia MJ, Hutzler LH, Bosco JA III. J Healthc Qual. 2015;37:126-132.

By tracking improper surgical bookings and observing time-out procedures, this study measured near misses for wrong-site surgery and provided education about correct procedures when they encountered errors. After this education, surgical booking and time-out procedures improved.

Web Resource > Multi-use Website

Joint Commission Center for Transforming Healthcare.

The Joint Commission.

The Joint Commission has traditionally focused on accreditation of health care organizations and, through its Joint Commission Resources arm, on quality improvement (QI) in areas related to its accreditation functions. In the first major initiative under the leadership of new president Dr. Mark Chassin, The Joint Commission launched this Center, which will focus on applying rigorous QI methods to improve safety in a number of challenging areas (the first three are hand hygiene, handoff communication, and preventing wrong site surgery) and disseminating the lessons from these efforts. This Web site provides more information about the Center and its goals.

Journal Article > Review

Wrong site surgery in otolaryngology–head and neck surgery.

Liou TN, Nussenbaum B. Laryngoscope. 2014;124:104-109.

This review discusses wrong site surgery in otolaryngology, along with preventive strategies such as the Universal Protocol, the WHO checklist, and radiofrequency identification tags.

Journal Article > Study

Priority patient safety issues identified by perioperative nurses.

Steelman VM, Graling PR, Perkhounkova Y. AORN J. 2013;97:402-418.

Perioperative nurses identified wrong-site surgery and medication errors as the most pressing patient safety concerns in their area of practice.

Journal Article > Study

Surgical never events in the United States.

Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgery. 2013;153:465-472.

More than a decade ago, stories of wrong site surgeries and retained surgical objects galvanized the patient safety movement. Despite public uproar and attention focused on these never events, such incidents continue to occur at alarming rates. This study found that surgeons make these mistakes more than 4000 times per year in the United States. Related malpractice payments have amounted to more than $1.3 billion over the last 20 years. Although this financial burden is substantial, it may pale in comparison to the degree of patient harm resulting from these preventable errors. An incident of wrong-site surgery is discussed in an AHRQ WebM&M commentary.

Newspaper/Magazine Article

Preventing wrong-site surgery in Minnesota: a 5-year journey.

Rydrych D, Apold J, Harder K. Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34.

Discussing a 5-year effort to report, analyze, and reduce wrong-site procedures, this magazine article details the lessons learned to help health care leaders implement improvements.

Journal Article > Commentary

Duplication of surgical site marking.

Davis JS, Karmacharya J, Schulman CI. J Patient Saf. 2012;8:151-152.

Describing a case of duplicate surgical site markings on a patient's legs, this article reveals how hospital protocol and medical record review prevented wrong-site surgery.

Audiovisual

Using the Targeted Solutions Tool for wrong site surgery: is your organization at risk?

Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; February 13, 2012.

This video presents a tool designed to help prevent wrong-site surgery and improve safety in hospitals.

Journal Article > Study

The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery.

James MA, Seiler JG 3rd, Harrast JJ, Emery SE, Hurwitz S. J Bone Joint Surg Am. 2012;94:e2(1-12).

This study found that wrong-site surgeries continued to occur despite adoption of "Sign Your Site" initiatives and implementation of a Universal Protocol. The most common errors reported were related to wrong-level spine surgery.

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